5 1 y57569ae5.txt FORM 5 --------------------------- OMB APPROVAL --------------------------- ------ OMB Number: 3235-0362 FORM 5 Expires: September 30, 1998 ------ Estimated average burden hours per response .... 1.0 --------------------------- / / Check box if no U.S. SECURITIES AND EXCHANGE COMMISSION longer subject to WASHINGTON, DC 20549 Section 16. Form 4 or Form 5 ANNUAL STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP obligations may continue. See Filed pursuant to Section 16(a) of the Securities Instruction 1(b) Exchange Act of 1934, / / Form 3 Holdings Section 17(a) of the Public Utility Reported Holding Company Act of 1935 or Section 30(f) of / / Form 4 the Investment Company Act Transactions of 1940 Reported ------------------------------------------------------------------------------------------------------------------------------------ 1. Name and Address of Reporting Person* 2. Issuer Name and Ticker or Trading Symbol 6. Relationship of Reporting Person(s) Dreher Jr. Richard L. Hanover Capital Mortgage Holdings, Inc. HCM to Issuer (Check all applicable) --------------------------------------------------------------------------------------------- Director 10% Owner (Last) (First) (Middle) 3. I.R.S. Identification 4. Statement for ---- --- Number of Reporting Month/Year XX Officer (give Other (Specify 635 Fairfield Circle Person, if an entity 12/01 ---- title --- below) ------------------------------------------- (Voluntary) ------------------- below) (Street) 5. If Amendment, Date of Original V.P. Finance (Month/Year) ------------------------ Westfield NJ 07090 ------------------------------------------- 7. Individual or Joint/Group Reporting (City) (State) (Zip) (Check applicable line) XX Form Filed by One Reporting Person ---- Form Filed by More than One ---- Reporting Person ------------------------------------------------------------------------------------------------------------------------------------ TABLE 1 -- NON-DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED ------------------------------------------------------------------------------------------------------------------------------------ 1. Title of Security 2. Trans- 3. Transac- 4. Securities Acquired (A) 5. Amount of Se- 6. Owner- 7. Nature (Instr. 3) action tion or Disposed of (D) curities Benefi- ship of In- Date Code (Instr. 3, 4 and 5) cially Owned at Form: direct (Instr. 8) end of Issuer's Direct Benefi- (Month/ Fiscal Year (D) or cial Day/ ---------------------------- (Instr. 3 and 4) Indirect Owner- Year) Amount (A) or Price (I) ship (D) (Instr. 4) (Instr. 4) ------------------------------------------------------------------------------------------------------------------------------------ Common Stock 8/10/01 X 1,000 A 3.875 1,600 D ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ *If the form is filed by more than one reporting person, see instruction 4(b)(v). (Over) SEC 2270 (7-97) Potential persons who are to respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB control number.
FORM 5 (CONTINUED) TABLE II -- DERIVATIVE SECURITIES ACQUIRED, DISPOSED OF, OR BENEFICIALLY OWNED (E.G., PUTS, CALLS, WARRANTS, OPTIONS, CONVERTIBLE SECURITIES) ------------------------------------------------------------------------------------------------------------------------------------ 1. Title of Derivative 2. Conver- 3. Trans- 4. Trans- 5. Number of 6. Date Exer- 7. Title and Amount 8. Price Security sion or action action Derivative cisable and of Underlying of (Instr. 3) Exercise Date Code Securities Ac- Expiration Securities Deriv- Price of (Month/ (Instr. 8) quired (A) or Date (Instr. 3 and 4) ative Deriv- Day/ Disposed of (D) (Month/Day/ Secur- ative Year) (Instr. 3, 4, Year) ity Security and 5) (Instr. 5) ----------------------------------- Date Expira- Amount or --------------- Exer- tion Title Number of (A) (D) cisable Date Shares ------------------------------------------------------------------------------------------------------------------------------------ Stock Option * 3.875 5/18/00 A 3000 * * Common 3000 Stock ------------------------------------------------------------------------------------------------------------------------------------ Stock Option * 3.875 8/10/01 X 1000 * * Common 1000 3.875 Stock ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------- 1. Title of Derivative 9. Number of 10. Ownership 11. Nature of Security Derivative of Derivative Indirect (Instr. 3) Securities Security: Beneficial Beneficially Direct (D) Ownership Owned at End or Indirect (I) (Instr. 4) of Year (Instr. 4) (Instr. 4) ------------------------------------------------------------------------------------------------------- D ------------------------------------------------------------------------------------------------------- 2000 D ------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- Explanation of Responses: * Grant of options exercisable as follows: 1/3 on or after 5/18/01, 1/3 on or after 5,18/02, 1/3 on or after 5/18/03, options expire 5/17/10. **Intentional misstatements or omissions of facts constitute Federal Criminal Violations. /s/ Richard Dreher Jr. 2/13/02 See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a). ------------------------------- ------- **Signature of Reporting Person Date Note. File three copies of this Form, one of which must be manually signed. Page 2 If space provided is insufficient, see Instruction 6 for procedure. SEC 2270 (7/97) Potential persons who are to respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB number.